NUR 2571 Exam 4 Actual Exam V3 | NUR 2571 Professional Nursing II /
PN2 (NUR2571 Exam 4) | Rasmussen
1. A patient is in the emergent phase of a major burn injury. Which laboratory result should
the nurse expect to observe during this stage?
A. Hypernatremia
B. Hyperkalemia
C. Decreased Hemoglobin
D. Metabolic Alkalosis
Answer: B
Rationale: During the emergent phase of a burn, massive cell destruction causes the
release of intracellular potassium into the extracellular space, leading to hyperkalemia.
Sodium typically moves into the interstitial space (hyponatremia) due to increased
capillary permeability. Hemoconcentration usually occurs rather than a decrease in
hemoglobin because of significant fluid loss.
2. A nurse is caring for a patient with septic shock. Which assessment finding indicates that
the patient is progressing to the ‘cold’ or late stage of shock?
A. Mottled, cool extremities
B. Bounding peripheral pulses
C. Warm, flushed skin
D. Increased cardiac output
Answer: A
Rationale: In the late stage of septic shock, the body’s compensatory mechanisms fail,
leading to decreased cardiac output and significant vasoconstriction. This results in
mottled, cool skin as blood is shunted away from the periphery to vital organs. The ‘warm’
phase is characterized by vasodilation and high cardiac output, which precedes this late
stage.
3. Using the Parkland formula, calculate the total fluid resuscitation required in the first 24
hours for a 70 kg patient with 40% total body surface area (TBSA) burns.
A. 11,200 mL
B. 5,600 mL
C. 2,800 mL
D. 8,400 mL
,Answer: A
Rationale: The Parkland formula is 4 mL x Weight (kg) x % TBSA. For this patient, the
calculation is 4 x 70 x 40 = 11,200 mL. The nurse must remember that half of this total
volume is administered in the first 8 hours post-injury.
4. A patient with Acute Respiratory Distress Syndrome (ARDS) is being mechanically
ventilated with High Positive End-Expiratory Pressure (PEEP). The nurse should monitor for
which side effect of PEEP?
A. Increased cardiac output
B. Pneumothorax
C. Hypertension
D. Respiratory alkalosis
Answer: B
Rationale: High levels of PEEP increase intrathoracic pressure, which can lead to
barotrauma and potential pneumothorax. Furthermore, the increased pressure can
decrease venous return to the heart, potentially lowering cardiac output and blood
pressure. The nurse must perform frequent lung assessments to detect early signs of air
leaks or diminished breath sounds.
5. A patient is admitted with Disseminated Intravascular Coagulation (DIC). Which laboratory
finding is most consistent with this diagnosis?
A. Decreased D-dimer levels
B. Prolonged Prothrombin Time (PT)
C. Increased Fibrinogen levels
D. Increased Platelet count
Answer: B
Rationale: DIC involves the depletion of clotting factors and platelets, leading to prolonged
clotting times such as PT and PTT. D-dimer levels would be increased as a result of fibrin
degradation from excessive clot breakdown. Fibrinogen levels would be decreased because
they are being consumed during the abnormal clotting process.
6. A patient in the Intensive Care Unit has a high-pressure alarm sounding on their
mechanical ventilator. Which action should the nurse take first?
A. Suction the patient’s airway
B. Call the respiratory therapist
C. Auscultate the patient’s lung sounds
, D. Disconnect the patient and use a manual resuscitator bag
Answer: C
Rationale: The first step in responding to a ventilator alarm is to assess the patient’s
physiological status and airway. Auscultating lung sounds helps identify causes such as
secretions, bronchospasm, or a pneumothorax. If the patient is in acute distress and the
cause cannot be identified, then manual ventilation would be the next priority.
7. The nurse is triaging victims at the scene of a mass casualty event. Which patient should be
assigned a ‘Red’ tag?
A. A patient with a sucking chest wound and cyanosis
B. A patient with an open fracture of the tibia
C. A patient who is pulseless and non-breathing
D. A patient with minor abrasions and anxiety
Answer: A
Rationale: A Red tag indicates an immediate threat to life that is treatable, such as a
sucking chest wound which requires urgent intervention for survival. Open fractures are
typically ‘Yellow’ (delayed), and minor injuries are ‘Green’ (minimal). Pulseless/non-
breathing victims in a mass casualty are typically tagged ‘Black’ (expectant) to prioritize
resources for those with a higher chance of survival.
8. A patient with a history of an acute myocardial infarction is now showing signs of
Cardiogenic Shock. Which medication should the nurse anticipate administering to increase
contractility without significantly increasing heart rate?
A. Epinephrine
B. Dobutamine
C. Atropine
D. Nitroglycerin
Answer: B
Rationale: Dobutamine is an inotropic agent that increases myocardial contractility, which
helps improve cardiac output in patients with cardiogenic shock. While it can increase
heart rate, its primary effect at moderate doses is improved pump function. Epinephrine is
less selective and significantly increases oxygen demand, which could worsen an MI.
9. A patient with deep partial-thickness burns on the chest and arms is being treated with
silver sulfadiazine. Which laboratory value should the nurse monitor specifically for side
effects of this medication?
A. Blood Urea Nitrogen (BUN)
PN2 (NUR2571 Exam 4) | Rasmussen
1. A patient is in the emergent phase of a major burn injury. Which laboratory result should
the nurse expect to observe during this stage?
A. Hypernatremia
B. Hyperkalemia
C. Decreased Hemoglobin
D. Metabolic Alkalosis
Answer: B
Rationale: During the emergent phase of a burn, massive cell destruction causes the
release of intracellular potassium into the extracellular space, leading to hyperkalemia.
Sodium typically moves into the interstitial space (hyponatremia) due to increased
capillary permeability. Hemoconcentration usually occurs rather than a decrease in
hemoglobin because of significant fluid loss.
2. A nurse is caring for a patient with septic shock. Which assessment finding indicates that
the patient is progressing to the ‘cold’ or late stage of shock?
A. Mottled, cool extremities
B. Bounding peripheral pulses
C. Warm, flushed skin
D. Increased cardiac output
Answer: A
Rationale: In the late stage of septic shock, the body’s compensatory mechanisms fail,
leading to decreased cardiac output and significant vasoconstriction. This results in
mottled, cool skin as blood is shunted away from the periphery to vital organs. The ‘warm’
phase is characterized by vasodilation and high cardiac output, which precedes this late
stage.
3. Using the Parkland formula, calculate the total fluid resuscitation required in the first 24
hours for a 70 kg patient with 40% total body surface area (TBSA) burns.
A. 11,200 mL
B. 5,600 mL
C. 2,800 mL
D. 8,400 mL
,Answer: A
Rationale: The Parkland formula is 4 mL x Weight (kg) x % TBSA. For this patient, the
calculation is 4 x 70 x 40 = 11,200 mL. The nurse must remember that half of this total
volume is administered in the first 8 hours post-injury.
4. A patient with Acute Respiratory Distress Syndrome (ARDS) is being mechanically
ventilated with High Positive End-Expiratory Pressure (PEEP). The nurse should monitor for
which side effect of PEEP?
A. Increased cardiac output
B. Pneumothorax
C. Hypertension
D. Respiratory alkalosis
Answer: B
Rationale: High levels of PEEP increase intrathoracic pressure, which can lead to
barotrauma and potential pneumothorax. Furthermore, the increased pressure can
decrease venous return to the heart, potentially lowering cardiac output and blood
pressure. The nurse must perform frequent lung assessments to detect early signs of air
leaks or diminished breath sounds.
5. A patient is admitted with Disseminated Intravascular Coagulation (DIC). Which laboratory
finding is most consistent with this diagnosis?
A. Decreased D-dimer levels
B. Prolonged Prothrombin Time (PT)
C. Increased Fibrinogen levels
D. Increased Platelet count
Answer: B
Rationale: DIC involves the depletion of clotting factors and platelets, leading to prolonged
clotting times such as PT and PTT. D-dimer levels would be increased as a result of fibrin
degradation from excessive clot breakdown. Fibrinogen levels would be decreased because
they are being consumed during the abnormal clotting process.
6. A patient in the Intensive Care Unit has a high-pressure alarm sounding on their
mechanical ventilator. Which action should the nurse take first?
A. Suction the patient’s airway
B. Call the respiratory therapist
C. Auscultate the patient’s lung sounds
, D. Disconnect the patient and use a manual resuscitator bag
Answer: C
Rationale: The first step in responding to a ventilator alarm is to assess the patient’s
physiological status and airway. Auscultating lung sounds helps identify causes such as
secretions, bronchospasm, or a pneumothorax. If the patient is in acute distress and the
cause cannot be identified, then manual ventilation would be the next priority.
7. The nurse is triaging victims at the scene of a mass casualty event. Which patient should be
assigned a ‘Red’ tag?
A. A patient with a sucking chest wound and cyanosis
B. A patient with an open fracture of the tibia
C. A patient who is pulseless and non-breathing
D. A patient with minor abrasions and anxiety
Answer: A
Rationale: A Red tag indicates an immediate threat to life that is treatable, such as a
sucking chest wound which requires urgent intervention for survival. Open fractures are
typically ‘Yellow’ (delayed), and minor injuries are ‘Green’ (minimal). Pulseless/non-
breathing victims in a mass casualty are typically tagged ‘Black’ (expectant) to prioritize
resources for those with a higher chance of survival.
8. A patient with a history of an acute myocardial infarction is now showing signs of
Cardiogenic Shock. Which medication should the nurse anticipate administering to increase
contractility without significantly increasing heart rate?
A. Epinephrine
B. Dobutamine
C. Atropine
D. Nitroglycerin
Answer: B
Rationale: Dobutamine is an inotropic agent that increases myocardial contractility, which
helps improve cardiac output in patients with cardiogenic shock. While it can increase
heart rate, its primary effect at moderate doses is improved pump function. Epinephrine is
less selective and significantly increases oxygen demand, which could worsen an MI.
9. A patient with deep partial-thickness burns on the chest and arms is being treated with
silver sulfadiazine. Which laboratory value should the nurse monitor specifically for side
effects of this medication?
A. Blood Urea Nitrogen (BUN)
